Hospice Foundation of America

Signs of Approaching Death

Note: This is a general picture. It will vary greatly according to the cause of
death, the person's general health, medications and any other significant factors.

All dying experiences are unique and influenced by many factors, such as the particular
illness and the types of medications being taken, but there are some physical changes
that are fairly common. For some, this process may take weeks; for others, only
a few days or hours.

For most dying persons, activity decreases significantly in the final days and hours
of life. They speak and move less and may not respond to questions or show little
interest in their surroundings. They have little, if any, desire to eat or drink.

As you hold their hand, you may notice that they feel cold. When a person is dying,
his or her body temperature can go down by a degree or more. Blood pressure will
also gradually lower and blood flow to the hands and feet will decrease.

When a person is just hours from death, breathing often changes from a normal rate
and rhythm to a new pattern of several rapid breaths followed by a period of no
breathing. This is known as “Cheyne-Stokes” breathing—named for the person who first
described it. Coughing can also be common as the body’s fluids begin to build up
in the lungs. Fluid that accumulates in the lungs also causes “rales” and “rattles.”
This breathing sound is often distressing to caregivers but it is not an indication
of pain or suffering. The secretions that cause these sounds can be dried up with
a medication called atropine delivered via injection, scopolamine (oral or trans-dermal),
or a small dose of liquid morphine. The oral administration of a small amount of
a common eye drop solution usually prescribed to reduce the amount of tears can
also help reduce the amount of lung fluid. On the other hand, when lung secretions
are thick or dry, running a vaporizer in the room can ease breathing.

As death approaches, skin color is likely to change from the normal pinkish tone
to a duller, darker, grayish hue. The fingernail beds may also become bluish rather
than the normal pink.

Because the central nervous system is directly impacted by the dying process, your
loved one may sometimes be fully awake and other times not responsive. Often before
death, people will lapse into a coma. A coma is a deep state of consciousness in
which a person cannot be aroused. Persons in a coma may still hear what is said
even when they no longer respond. They may also feel something that could cause
pain, but not respond outwardly. Caregivers, family, and physicians should always
act as if the dying person is aware of what is going on and is able to hear and
understand voices. In fact, hearing is one of the last senses to lapse before death.

It is not unusual for dying persons to experience sensory changes. Sometimes they
misperceive a sound or get confused about some physical object in the room. They
might hear the wind blow but think someone is crying or see the lamp in the corner
and think someone is standing there. These types of misperceptions are called illusions.
They are misunderstandings about something that is actually in their surroundings.

Another type of misperception is hallucination. Dying persons may hear voices that
you cannot hear, see things that you cannot see, or feel things that you are unable
to touch or feel.

Some dying persons confuse reality and might think that others are trying to hurt
them or cause them harm. Or, they can come to believe that they are much more powerful
than they really are and think that they can accomplish things that are not possible.
These types of misconceptions are called delusions of persecution and delusions
of grandeur.

If you want more information about the sequence of events leading up to the moment
of death, we suggest the book How We Die by Sherwin Nuland, M.D. (New York: Knopf,
1993).

Copyright 2008 Hospice Foundation of America. All Rights Reserved.

Q: My father has cancer and his physician has recommended hospice.
My family has…

A: Hospice care is a covered benefit under Medicare for patients
with a prognosis of 6 months or less. Medicaid covers hospice services in most states.
Many private health…